Physical and Health Assessment Final
Which of the following is an example of a violation in patient confidentiality? (Select all that apply.) Select one: a. Discussing patient information in the cafeteria b. Leaving copies of confidential patient information lying in a nonsecluded area on a desk c. Providing test results to a family member who has been given information privileges by the patient d. Leaving a computer screen with patient information in view of a visitor e. Discussing patient information in the elevator
A, B or D
Which of the following is an example of a therapeutic communication technique? (Select all that apply.) Select one or more: a. Restating and reflecting b. Silence c. Clarification d. False Reassuring e. Giving advice
A, B, and C
Registered nurse is completing an assessment, which findings will the nurse report as subjective data? (Select all that apply) Select one or more: a. Patient's temperature. b. Patient blood pressure results taken by the UAP. c. Patient's level of pain. d. Patient describing he is very excitement about next day discharge. e. Patient's wound size
C and D Objective data are observations or measurements of a patient's health status. In this question, the appearance of the wound and the patient's temperature are objective data. Pacing is an observable patient behavior and is also considered objective data.
Patients resting heart rate is 85 beats/minute and the stroke volume of 6 mL/beat, what is the patient's total cardiac output (mL per minute) knowing that Cardiac output is equal to Strike Volume x heart rate? Select one: a. 145 beats/min b. 145 mL/min c. 510 mL/min d. 510 beats/min
C. 510 mL/min
A registered nurse is providing nursing care to a group of patients. Which actions are considered to be indirect care interventions? (Select all that apply) Select one or more: a. Documenting wound dressing in the patient's chart b. Administer and IV medication c. Teaching a new patient about side effects of medications d. Ordering medication from the pharmacy to the unit for a new patient e. Ambulating a post-surgical patient
D and A Documenting wound care and ordering prescriptions are example of an indirect intervention. All of the interventions listed (ambulating, inserting a feeding tube and IV catheter, and teaching) are direct care interventions involving patient and nurse interaction, except documenting wound care.
For the abdominal assessment, place these assessment techniques in the correct order, with A being performed first and E being performed last. Select all that apply: A. Deep palpation, all quadrants B. Light palpation, all quadrants C Auscultate bowel sounds D. Inspect the abdomen for contour, skin characteristics, and pulsations E. Percuss all quadrants
D, C, E, B, A After inspection, first perform auscultation of bowel sounds so that the sounds are not altered by percussion and palpation. Follow auscultation by percussion, then light palpation, then deep palpation.
The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? a. Snellen b. Shetllen c. Smoollen d. Schwellon
a. Snellen The Snellen eye chart is most widely used for vision examinations. The other options are not tests for vision examinations.
The direction of blood flow through the heart is best described by which of these?
Right atrium -> right ventricle -> pulmonary artery -> lungs -> pulmonary vein -> left atrium -> left ventricle Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood and it is then returned to the left atrium by the pulmonary vein. It goes from there to the left ventricle and then out to the body through the aorta.
Which identifies the route of transmission of tuberculosis (TB)? Select one: a. The airborne route b. The enteric route c. Hand to mouth (Contact) d.Blood and body fluids
a. The airborne route
The nurse administered 5 mg of Morphine IM at 10:00 A.M. to a patient experiencing breakthrough pain. At what time will the nurse change patient's wound dressing? Select one: a. 1030 b. 1015 c. 1005 d. 1150
a. 1030
Patient has gained 2.2 lb of weight in a 24 hour time period, the nurse is suspecting that the patient is retaining fluid, how much fluid did the patient retain knowing 1 kg is equal to 1000 mL? Select one: a. 1L b. 4.4 kg c. 500 ml d. 2.2 L
a. 1L
The patient complains of a headache and is prescribed Acetaminophen (Tylenol) 1,000 mg p.o., PRN, Q 4-6 hours. What you have are 500 mg extra-strength tablets. How many tablets you should administer? Select one: a. 2 tablet exactly b. Less than 1 tablet c. ½ tablet d. 1 tablet exactly
a. 2 tablets exactly
The patient's blood pressure is 130/80. Which value will the nurse record for the pulse pressure? Select one: a. 50 b. 130 c. 80 d. 130/80
a. 50
The nurse is preparing to teach a class on cardiovascular assessment. When explaining a thrill, what should the nurse include in the teaching? Select one: a. A vibration that is palpable. b. Palpated in the right epigastric area. c. A murmur auscultated at the third intercostal space d. Associated with ventricular hypertrophy.
a. A vibration that is palpable A thrill is a vibratory sensation felt on the skin overlying an area of turbulence and indicates a loud heart murmur usually caused by an incompetent heart valve.
A patient recovering from a leg fracture after a fall reports having a dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is a priority? Select one: a. Administer pain medication as ordered. b. Assist the patient to walk in the room with crutches. c. Obtain a walker for the patient. d. Consult physical therapy.
a. Administer pain medication as ordered.
A nurse is caring for a group of patients. Which patient will the nurse see first? Select one: a. An sleeping infant with P-188 and R-65 b. A toddler with P-90 and R-26 c. An adult that is excercizing with P-108 and R-24 d. An adolescent with P-90 and R-20
a. An sleeping infant with P-188 and R-65
The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? Select one: a. Ask the patient to rate and describe the pain. b. Call the rapid response team. c. Administer pain-relief medications. d. Start an intravenous (IV) line.
a. Ask the patient to rate and describe the pain.
A registered nurse is caring for an infant and is obtaining the patient's vital signs. The best site for the nurse to obtain the infant's pulse would be: Select one: a. Brachial artery b. Popliteal artery c. Femoral artery d. Radial artery
a. Brachial artery
Registered nursing assistive personnel (NAP) is taking vital signs and reports that an adult patient's pulse is 132, and pulse oxygenation level is 89%; what should the nurse do next? Select one: a. Check the equipment for accuracy and take vital signs by yourself. b. Instruct the NAP to assess the patient's other vital signs. c. Ask the NAP to assess the patient's condition. d. Disregard the report.
a. Check the equipment for accuracy and take vital signs by yourself.
A 33-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment. What other finding should the nurse expect? Select one: a. Chloasma b. Keratoses c. Acrochorodons d. Xerosia
a. Chloasma Melasma (chloasma) is an acquired, chronic, recurrent symmetrical hyper pigmentation of the forehead and cheeks which develops in some women, especially those living in areas of intense UV radiation, who are pregnant or taking oral contraceptives. Keratoses is a noncancerous skin condition that appears as a waxy brown, black, or tan growth. An acrochordon is a small, soft, common, benign, usually pedunculate neoplasm that is found particularly in persons who are obese. Xerosia is rough, dry skin with that may have scales or small cracks.
After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: a. Empty the bladder. b. Completely disrobe. c. Lie on the examination table. d. Walk around the room.
a. Empty the bladder Before beginning the examination, the nurse should ask the person to empty the bladder (save the specimen if needed), disrobe except for underpants, put on a gown, and sit with legs dangling off side of the bed or table.
Nine-year-old Eduard has a difficult time making friends at his school and being chosen to play on the team. He also has trouble completing his homework and, as a result, receives little positive feedback from his parents or teacher. According to Erikson's theory, failure at this stage of development results in: Select one: a. Feelings of inferiority. b. Mistrust. c.A poor sense of identity d. A sense of guilt
a. Feelings of inferiority.
During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse, the PMI? Select one: a. Fifth left intercostal space at the midclavicular line b. Third left intercostal space at the midclavicular line c. Fourth left intercostal space at the anterior axillary line d. Fourth left intercostal space at the sternal border
a. Fifth left intercostal space at the midclavicular line
A female patient tells the nurse that she has four children and has had three pregnancies. How should the nurse document this? a. Gravida 3, para 4 b. Gravida 4, para 3 c. This information cannot be documented using the terms gravida and para. d. "The patient seems to be confused about how many times she has been pregnant."
a. Gravida 3, para 4 Gravida refers to the number of pregnancies, and para refers to the number of children. One pregnancy was with twins.
A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex. The nurse has just tested which cranial nerves? a. IX, X b. IX, XII c. X, XII d. XI, XII
a. IX, X Cranial nerves IX and X are being tested by having the patient say "ahh," noting the mobility of the uvula, and when assessing the patient's gag reflex.
In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. What is the reason for this? Select one: a. It is the most common location of breast tumors b. It is the largest quadrant of the breast c. It is more prone to injury and calcifications than other locations in the breast d. It is where the majority of suspensory ligaments attach
a. It is the most common location of breast tumors
A patient has just returned from a liver biopsy and is ordered to lie on her right side for 1 hour. An IV is in the left basilic vein. What site do you instruct the nursing assistive personnel (NAP) to use to obtain a blood pressure reading? Select one: a. Left leg b. Left arm c. Right arm d. Right leg
a. Left leg
What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease? Select one: a. Listen with the bell of the stethoscope to assess for bruits b. Instruct the patient to take slow deep breaths during auscultation. c. Palpate the artery in the upper one-third of the neck. d. Simultaneously palpate both arteries to compare the amplitude
a. Listen with the bell of the stethoscope to asses for bruits Lightly apply the bell of the stethoscope over the carotid artery, and while listening, have the patient take a breath, exhale, and hold it briefly.
During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? Select one: a. Listen to at least one full respiration in each location. b. If the patient is modest, listen to sounds over his or her clothing or hospital gown. c. Listening as the patient inhales and then go to the next site during exhalation. d. Instructing the patient to breathe in and out rapidly while listening to the breath sounds.
a. Listening to at least one full respiration in each location
The nurse is assessing a 75-year-old man. What should the nurse expect when performing the mental status portion of the assessment? Select one: a. May take a little longer to respond, but his general knowledge and abilities should not have declined b. Will have no decrease in any of his abilities, including response time. c. Will exhibit had a decrease in his response time because of the loss of language and a decrease in general knowledge. b. Will have difficulty on tests of remote memory because this ability typically decreases with age.
a. May take a little longer to respond, but his general knowledge and abilities should not have declined The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected.
After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: Select one: a. Objective b. Subjective c. Introspective d. Reflective
a. Objective Objective evidence refers to visible, measurable findings obtained by a medical examination, tests, or diagnostic imaging. Subjective is information that is reported by the patient, BUT can't be verified or perceived by the examiner. Introspection is an examination of one's own thoughts and feelings. Reflective is a communication skill in which a counselor or other professional reiterates either the content or the feeling message of the patient.
The patient has had a stroke that has affected the ability to speak. The patient can not respond correctly to questions and instructions because the patient won't understand the spoken language but the patient can speak coherently. Which type of aphasia is the patient experiencing? Select one: a. Sensory b. Motor c. Receptive d. Combination
a. Sensory or c. Receptive
What component of the conduction system in the heart is referred to as the pacemaker of the heart? Select one: a. Sinoatrial (SA) node b. Bundle branches c. Bundle of His d. Atrioventricular (AV) node
a. Sinoatrial (SA) node The SA node is the heart's natural pacemaker. The bundle branches are offshoots of the bundle of His in the heart's ventricle. The bundle of His is a collection of heart muscle cells specialized for electrical conduction that transmits the electrical impulses from the AV node to the point of the apex of the fascicular branches via the bundle branches. The AV node is a part of the electrical conduction system of the heart that coordinates the top of the heart. It electrically connects the atria and ventricles.
A patient asks the nurse what the term polypharmacy means. The nurse defines this term as Select one: a. The concurrent use of many medications b. Multiple side effects experienced when taking a medication c. The risks of medication effects due to aging. d. Too many adverse drug effects reported to the pharmacy.
a. The concurrent use of many medications
During inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicates that which cranial nerve is intact? a. VII b. IX c. XI d. XII
a. VII Cranial nerve VII is responsible for facial symmetry
During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences: a. Vertigo. b. Tinnitus. c. Syncope. d. Dizziness.
a. Vertigo Vertigo is the sensation of moving around in space (subjective) or of having objects move about the person (objective) and is a result of a disturbance of equilibratory apparatus.
When performing a physical assessment, the technique the nurse will always use first is: Select one: a. inspection. b. percussion. c. palpation. d. auscultation.
a. inspection.
When assessing the QUALITY of a patient pain, which is the best question the nurse should ask? Select one: a. "Is the pain only at night?" b. "What does your pain feel like?" c. "When did the pain start?" d. "Is it a sharp pain?"
b. "What does your pain feel like?" Quality of the pain. This is the patient's description of the pain
The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment? Select one: a. Last menstrual period 1 month ago b. 2 * 5 cm scar on right lower forearm c. Patient's history of allergies d. Patient's use of medications at home
b. 2 * 5 cm scar on right lower forearm
During report, the nurse hears that a patient is experiencing hallucinations. Which is an example of a auditory hallucination? Select one: a. A woman hears the doorbell ring and goes to answer it, but no one is there b. A man hears that his dead wife is talking to him. c. A child thiks there is a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. d. A man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket
b. A man hears that his dead wife is talking to him.
The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel (CNN)? Select one: a. Selecting appropriate route and device b. Assessing changes in body temperature c. Clean the thermometer d. Obtaining temperature measurement at ordered frequency
b. Assessing changes in body temperature
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Clubbing of the nails c. Scleroderma d. Pedal erythema
b. Clubbing of the nails Nail clubbing is a deformity of the finger or toenails associated with a number of diseases, mostly of the heart and lungs. Anasarca is a severe and generalized form of edema, with subcutaneous tissue swelling throughout the body. Scleroderma is a group of rare diseases that involve the hardening and tightening of the skin and connective tissues. Pedal Erythema is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation.
A 23 year old female presents complaining of hearing changes and balance issues. Which cranial nerve is most likely involved with her problems? Select one: a. Cranial Nerve XII b. Cranial Nerve VIII c. Cranial Nerve VII d. Cranial Nerve V
b. Cranial Nerve VIII CN VIII is the vestibulocochlear nerve which is involved in balance and hearing.
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis, what sound will the nurse hear? Select one: a. Tympany b. Dullness c. Resonance d. Hyperresonance
b. Dullness A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor. Tympany A hollow drum-like sound that is produced when a gas-containing cavity is tapped sharply. Tympany is heard if the chest contains free air (pneumothorax) or the abdomen is distended with gas. Hyperresonance on percussion indicates too much air is present within the lung tissue. Likely indicating: Emphysema or pneumothorax.
A patient with pleuritis has been admitted to the hospital and reports pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Friction rub c. Wheezing d. Crackles
b. Friction rub A pericardial friction rub is an audible medical sign used in the diagnosis of pericarditis. Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may also be called musical breathing or extra thoracic airway obstruction. Wheezing is a high-pitched whistling sound made while breathing. It's often associated with difficulty breathing. Crackles are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation.
A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following? Select one: a. Tachypnea b. Hypoventilation c. Chronic obstructive breathing d. Bradypnea
b. Hypoventilation Hypoventilation (also known as respiratory depression) occurs when ventilation is inadequate to perform needed gas exchange. Fast breathing Also called: Tachypnea Breathing that is abnormally rapid and often shallow. Chronic obstructive breathing is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing. Bradypnea is an abnormally slow breathing rate.
The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access device. Which nursing intervention is a priority in this procedure? Select one: a. Gather all available supplies b. Maintain aseptic technique. c. Provide comfort d. Review the duration of the procedure with the patient.
b. Maintain aseptic technique.
An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: a. Posture. b. Mobility. c. Mood and affect. d. Physical deformity.
b. Mobility Use of assistive devices would be documented under the mobility section. The other responses are all other categories of the general appearance section of the health history.
As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. Your best reply is: Select one: a. Nail polish attracts microorganisms and contaminates the finger sensor. b. Nail polish interferes with sensor function. c. Nail polish decreases oxygen saturation. d. Nail polish creates excessive heat in sensor probe.
b. Nail polish interferes with sensor function.
The nurse is working in a clinic that is designed to provide health education and immunizations. As such, this clinic is designed to provide Select one: a. Tertiary prevention b. Primary prevention c. Secondary prevention. d. Diagnosis and prompt intervention.
b. Primary prevention
Which of these statements is true regarding the recording of data from the history and physical examination? a. Use long, descriptive sentences to document findings. b. Record the data as soon as possible after the interview and physical examination. c. If the information is not documented, then it can be assumed that it was done as a standard of care. d. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.
b. Record the data as soon as possible after the interview and physical examination The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short clear phrases and should avoid redundant phrases and descriptions.
Patient that is a recent immigrant who does not speak English is alert and requires hospitalization. What is the initial action that the nurse must take prior to starting an assessment of this patient? Select one: a. Ask a family member to translate what the nurse is saying. b. Request an official interpreter. c. Use hand gestures and medical equipment while explaining in English. d. Notify the nursing manager that the patient doesn't speak English.
b. Request an official interpreter.
When assessing the pupillary light reflex, the nurse should use which technique? Select one: a. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction b. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction c. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose
b. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction
Which symptom is an expected cognitive change in the older adult patient? Select one: a.Disorientation to person b. Slower reaction time c. Poor judgment d. Loss of language skills
b. Slower reaction time
The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? Select one: a. First, palpate a tender area to avoid any discomfort that the patient may experience. b. Start with light palpation to detect surface characteristics and to accustom the patient to being touched c. Always avoid palpation of reported "tender" areas because this may cause the patient pain d. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths.
b. Start with light palpation to detect surface characteristics and to accustom the patient to being touched
The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment? Select one: a. The inspection always yields little information. b. The inspection takes time and reveals a surprising amount of information. c. The inspection may be somewhat uncomfortable for the expert nurse. d. Inspection requires a quick glance at the patient's body systems before proceeding on with palpation.
b. The inspection takes time and reveals a surprising amount of information. A focused inspection takes time and yields a surprising amount of information. Initially, the examiner may feel uncomfortable "staring" at the person without also "doing something." A focused assessment is much more than a "quick glance."
Which of these statements is true regarding the complete physical assessment? a. The male genitalia should be examined in the supine position. b. The patient should be in the sitting position for examination of the head and neck. c. The vital signs, height, and weight should be obtained at the end of the examination. d. To promote consistency between patients, the examiner should not vary the order of the assessment.
b. The patient should be in the sitting position for examination of the head and neck The head and neck should be examined in the sitting position to best palpate the thyroid and lymph nodes. The male patient should stand during examination of the genitalia. Vital signs are measured early in the assessment. The sequence of the assessment may need to vary according to different patient situations.
The nurse is unable to palpate the right radial pulse on a patient. What should the nurse do next? Select one: a. Use a goniometer to measure the pulsations b. Use a Doppler device to check for pulsations over the area c. Check for the presence of pulsations with a stethoscope d. Auscultate over the area with a fetoscope
b. Use a Doppler device to check for pulsations over the area Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? Select one: a. Perform the confrontation test. b. Use the Snellen chart positioned 20 feet away from the patient. c. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches. d. Ask the patient to read the print on a handheld Jaeger card.
b. Use the Snellen chart positioned 20 feet away from the patient The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision
During a complete health assessment, how would the nurse test the patient's hearing? a. By observing how the patient participates in normal conversation b. Using the whispered voice test c. Using the Weber and Rinne tests d. Testing with an audiometer
b. Using the whispered voice test During the complete health assessment, the nurse should test hearing with the whispered voice test. The other options are not correct.
During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This is an example of: Select one: a. post-traumatic stress disorder b. obsessive-compulsive disorder (OCD) c. agoraphobia d. social phobia.
b. obsessive- compulsive disorder (OCD)
The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates: a. Lymphedema. b. Raynaud's disease. c. Arterial insufficiency. d. Venous insufficiency.
c. Arterial insufficiency Ulcerations on the tips of the toes and lateral aspect of the ankles are indicative of arterial insufficiency.
The registered nurse is teaching a group of older adult patients. Which teaching strategy is best for the nurse to use? Select one: a. Speak in a high pitch to help patients hear better. b. Avoid uncomfortable silence after questions by helping patients complete their statements. c. Ask patients to recall past experiences that correspond with their interests. d. Provide many topics of discussion at once to promote independence and making choices.
c. Ask patients to recall past experiences that correspond with their interests.
A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessments findings related to this condition? Select one: a. Diffuse infiltrates with areas of dullness upon percussion b. Absent or decreased breath sounds c. Chest pain that is worst on deep inspiration and dyspnea d. Productive cough with thin, frothy sputum
c. Chest pain that is worst on deep inspiration and dyspnea
During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect: a. Lymphedema. b. Raynaud's disease. c. Chronic arterial insufficiency. d. Chronic venous insufficiency.
c. Chronic arterial insufficiency Elevational pallor (marked) indicates arterial insufficiency.
Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? Select one: a. Temperature of 98.5° F b. Presbyopia c. Confusion d. Death of a spouse 8 months ago
c. Confusion
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: Select one: a. consider this an abnormal finding and refer the patient for additional treatment. b. perform deep palpation of this area for an underlying mass. c.consider this a normal finding. d. reposition the hands and attempt to percuss in this area again.
c. Consider this a normal finding Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.
The nurse should institute which type of precaution for a client diagnosed with Clostridium difficile and severe diarrhea? Select one: a. Droplet b. Airborne c. Contact d. Neutropenic
c. Contact
During an assessment of an older adult's skin, expected findings include which of the following? Select one: a. Good hydration b. Faster nail growth c. Decreased elasticity d. Increased elasticity
c. Decreased elasticity
What are the primary muscles of respiration? Select one: a. External obliques and pectoralis major b. Tapezii and rectus abdominis c. Diaphragm and intercostals d. Sternomastoids and scaleni
c. Diaphragm and intercostals The diaphragm is a thin skeletal muscle that sits at the base of the chest and separates the abdomen from the chest. It contracts and flattens when you inhale. This creates a vacuum effect that pulls air into the lungs. When you exhale, the diaphragm relaxes and the air is pushed out of lungs.
A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, "It hurts so bad." Which pain assessment tool would be the best choice when assessing this child's pain? Select one: a. Numeric rating scale b. Brief pain inventory c. Faces Pain Scale-Revised (FPS-R) d. Descriptor scale
c. Faces Pain Scale-Revised (FPS-R) Rating scales can be introduced at the age of 4 or 5 years. The Faces Pain Scale—Revised (FPS-R) is designed for use by children and asks the child to choose a face that shows "how much hurt (or pain) you have now." Young children should not be asked to rate pain by using numbers.
While recording in a patient's medical record, the nurse notices that a patient's Hematest results are positive. This means that there: a. Are crystals in his urine. b. Are parasites in his stool. c. Is occult blood in his stool. d. Are bacteria in his sputum.
c. Is occult blood is his stool If a stool is Hematest positive, then it indicates the presence of occult blood.
The nurse will measure a patient's near vision with which tool? a. Snellen eye chart with letters b. Snellen "E" chart c. Jaeger card d. Ophthalmoscope
c. Jaeger card The Jaeger card is used to measure near vision.
During an interview, the nurse states, "You mentioned having shortness of breath. Tell me more about that." Which verbal skill is used with this statement? Select one: a. Reflection b. Direct question c. Open-ended question d. Facilitation
c. Open-ended question An open-ended question is a question that cannot be answered with a "yes" or "no" response, or with a static response.
The nurse should wear gloves for which of these examinations? a. Measuring vital signs b. Palpation of the sinuses c. Palpation of the mouth and tongue d. Inspection of the eye with an ophthalmoscope
c. Palpation of the mouth and tongue Gloves should be worn when the examiner is exposed to the patient's body fluids.
A patient tells the nurse that "sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath." When documenting this information, the nurse would note: a. Orthopnea. b. Acute emphysema. c. Paroxysmal nocturnal dyspnea. d. Acute shortness of breath episode.
c. Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea occurs when the patient awakens from sleep with shortness of breath and needs to be upright to achieve comfort.
A registered nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse provide? Select one: a. Tertiary prevention b. Secondary prevention c. Primary prevention d. Continuing care
c. Primary prevention
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include which findings? Select one: a. Adventitious sounds and limited chest expansion b. Increased tactile fremitus and dull percussion tones c. Resonant percussion tones and symmetric tactile fremitus d. Absent voice sounds and hyperresonant percussion tones
c. Resonant percussion tones and symmetric tactile fremitus
When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination Select one: a. Wear sterile gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases. b. There is no need to wash one's hands after removing gloves, as long as the gloves are still intact c. Wash hands before and after every physical patient encounter d.Wear clean gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.
c. Wash hands before and after every physical patient encounter
The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group that the most important thing to do to prevent the spread of infection is to Select one: a. Clean the toys every night before putting them away b. Encourage parents to provide a multivitamin to the children. c. Wash their hands between each interaction with children. d. Ask the mother to give the drugs to her child.
c. Wash their hands between each interaction with children.
A patient is unable to shrug her shoulders against the nurse's resistant hands. What cranial nerve is involved with successful shoulder-shrugging? a. VII b. IX c. XI d. XII
c. XI Cranial nerve XI enables the patient to shrug her shoulders against resistance.
Which technique is correct when the nurse is assessing the radial pulse of a patient? Count the: Select one: a. take pulse for a full 2 minutes to detect any variation in amplitude. b. pulse for 15 seconds and multiply by four, if the rhythm is irregular c. pulse for 1 minute if the rhythm is irregular d. pulse for 10 seconds and multiply by six, if the patient has no history of cardiac abnormalities.
c. pulse for 1 minute if the rhythm is irregular
The most important step that the nurse can take to prevent transmission of microorganisms in the hospital setting is to: Select one: a. wear gloves during all contact with patients. b.wear protective eyewear at all times. c. wash hands before and after contact with each patient. d. clean the stethoscope with an alcohol swab between patients
c. wash hands before and after contact with each patient.
When assessing the quality of a patient's pain, the nurse should ask which question? Select one: a. "When did the pain start?" b. "Is it a sharp pain or dull pain?" c. "Is the pain a stabbing pain?" d. "What does your pain feel like?"
d. "What does your pain feel like?"
Which of the following patients is most at risk for tachycardia? Select one: a. A patient just admitted with hypothermia b. A 70-year-old male taking beta blockers c. A healthy professional soccer player d. A patient with a fever of 39.4°C (103°F)
d. A patient with a fever of 39.4°C (103°F)
When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart? Select one: a. Mitral and pulmonic b. Mitral and tricuspid c. Tricuspid and aortic d. Aortic and pulmonic
d. Aortic and pulmonic The second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base.
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention? Select one: a. Call for a stat electrocardiogram (ECG) Stat b. Prepare to administer cardiac-stimulating medications c. Request that the nursing assistant repeat the pulse check d. Assess the patient's apical pulse and evidence of a pulse deficit
d. Assess the patient's apical pulse and evidence of a pulse deficit
The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of: a. Lymphedema. b. Raynaud's disease. c. Chronic arterial insufficiency. d. Chronic venous insufficiency.
d. Chronic venous insufficiency Chronic venous insufficiency would present as firm brawny edema, coarse thickened skin, normal pulses, and brown discoloration.
The nurse is interviewing a male patient who has a hearing impairment and came in because of a cold. What techniques would be most beneficial in communicating with this patient? Select one: a. Request a sign language interpreter before meeting with him to help facilitate the communication b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading. c. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read. d. Determine the communication method he prefers.
d. Determine the communication method he prefers.
A woman has come to the clinic to seek help with a substance abuse problem. She admits to using cocaine just before arriving. Which of these assessment findings would the nurse expect to find when examining this woman? Select one: a. Dilated pupils, unsteady gait, and aggressiveness b. Pupil construction, lethargy, apathy, and dysphoria c. Constricted pupils, euphoria, and decreased temperature d. Dilated pupils, pacing, and psychomotor agitation
d. Dilated pupils, pacing, and psychomotor agitation A cocaine users appearance includes pupillary dilation, tachycardia or bradycardia, elevated or lowered blood pressure, sweating, chills, nausea, vomiting, and weight loss. The persons behavior includes euphoria, talkativeness, hyper vigilance, pacing, psychomotor agitation, impaired social or occupational functioning, fighting, grandiosity, and visual or tactile hallucinations.
During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This speech pattern is an example of: Select one: a. Confabulation b. Word salad c. Depression d. Echolalia
d. Echolalia
On admission, a patient weighs 165 pounds. The weight is recorded as 179 pounds on the second inpatient day. Which condition will the nurse assess for in this patient? Select one: a. Anorexia b. Increased nutritional intake c. Weight loss d. Fluid retention
d. Fluid retention
Registered nurse is providing oral care to an unconscious patient. Which one is considered to be a priority nursing action? Select one: a. Moisten the mouth using lemon-glycerin sponges. b. Use wet foam swabs to help remove all the plaque. c. Hold the patient's mouth open with gloved fingers all the time. d. Getting suctioning equipment to prevent aspiration
d. Getting suctioning equipment to prevent aspiration
The nurse is assessing for skin turgor in an elderly woman . Which technique will the nurse should use? Select one: a. Press lightly on the forearm. b. Grasp a fold of skin on the back of the hand. c. Press lightly on the fingertips. d. Grasp a fold of skin on the sternal area.
d. Grasp a fold of skin on the sternal area.
After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist, papules in a cauliflower-like patch around her introitus. This finding is most likely: a. Urethral caruncle. b. Syphilitic chancre. c. Herpes. d. Human papillomavirus.
d. Human papillomavirus Human papillomavirus appears in a flesh-colored, soft, moist, cauliflower-like patch of papules.
The nurse has just completed an examination of a patient's extra ocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves? a. II, III, VI b. II, IV, V c. III, IV, V d. III, IV, VI
d. III, IV, VI Extra ocular muscles are innervated by cranial nerves III, IV, and VI.
What does the review of systems provide the nurse? Select one: a. Physical findings r/t each system b. An opportunity to teach the patient medical terms c. Information necessary for the nurse to diagnose the patient's medical problem d. Information regarding health promotion practices
d. Information regarding health practices
A 55-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 38 years and recently lost over 10 pounds. Her vital signs on admission are: HR 114, BP 138/82, RR 22, tympanic temperature 36.8°C (98.2°F), and oxygen saturation 92%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy administered? Select one: a. Blood pressure 148/82 b. Oxygen saturation: 92% c. Respiratory rate: 26 per minute d. Oxygen saturation: 97%
d. Oxygen saturation: 97%
While examining a 48-year-old patient's eyes, the nurse notices that he had to move the handheld vision screener farther away from his face. The nurse would suspect: a. Myopia. b. Omniopia. c. Hyperopia. d. Presbyopia.
d. Presbyopia Presbyopia, the decrease in power of accommodation with aging, is suggested when the handheld vision screener card is moved farther away.
The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the: Select one: a. patient's vital signs. b. results of a CT scan. c. patient physical examination d. Subjective patient report
d. Subjective patient report
The nurse is assessing an alert adult patient's pain. What should the nurse know is the BEST indicator of pain? Select one: a. Results of a computerized axial tomographic scan b. Patient's vital signs c. Physical examination d. Subjective report from the patient
d. Subjective report from the patient The hierarchy affirms that the patient's self-report is the most reliable indicator of pain and the sole indicator of pain intensity.
When the nurse performs the confrontation test, the nurse has assessed: a. Extra ocular eye muscles (EOMs) b. Pupils (PERRLA). c. Near vision. d. Visual fields.
d. Visual fields The confrontation test assesses visual fields. The other options are not tested with the confrontation test.
The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? Select one: a. Whispered pectoriloquy b. Bronchophony c. Bronchial sounds d .Wheezes
d. Wheezes Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.
In performing a voice test to asses hearing, which of these actions would the nurse perform? Select one: a. Shield the lips so that the sound is muffled b. Stand approximately 4 feet away to ensure that the patient can really hear at this distance c. Ask the patient to place his or her finger in their ear to occlude outside noise d. Whisper a set of ransom numbers and letters, and then ask the patient to repeat them
d. Whisper a set of ransom numbers and letters, and then ask the patient to repeat them
During an examination, the nurse finds that a patient has excessive dryness of the skin. How should the nurse document this finding? a. Pruritus b. Seborrhea c. Alopecia d. Xerosis
d. Xerosis Xerosis cutis is the medical term for abnormally dry skin. Pruritus is defined as an unpleasant sensation that provokes the desire to scratch. Seborrhea is a skin condition that causes scaly patches and red skin, mainly on the scalp. Alopecia is sudden hair loss that starts with one or more circular bald patches that may overlap.
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should Select one: a. consider this an abnormal finding. b. reposition the hands and attempt to percuss in this area again. c. palpate this area for an underlying mass. d. consider this a normal finding.
d. consider this a normal finding.